Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow proper infection control techniques during a dressing change for a resident who was under Enhanced Barrier Precautions (EBP) due to multiple wounds, including a stage three pressure ulcer and a surgical incision. The RN performed wound care by cleansing the resident's coccyx wound and placed contaminated gauze on the resident's uncovered bedside table. Without changing gloves or performing hand hygiene, the RN proceeded to cut and apply a new dressing, moving from a dirty to a clean area without appropriate infection control measures. The RN confirmed during an interview that she did not change gloves or perform hand hygiene between tasks as required. After completing the dressing change, the RN removed her gloves but exited the resident's room still wearing her PPE gown. She then discarded the gown in a housekeeping cart trash bag located in the hallway, rather than removing and discarding it inside the resident's room as required by facility policy and CDC guidelines. This action was observed and confirmed by both the Housekeeper Director and the RN herself, who acknowledged the error during interviews. The facility's policies on Enhanced Barrier Precautions and wound care require that PPE be removed and discarded inside the resident's room and that hand hygiene be performed between dirty and clean tasks. The failure to follow these protocols during the dressing change had the potential to affect other residents on the same hall who were not under EBP, as contaminated PPE was improperly handled and disposed of outside the resident's room.